The Mater Hospital Multiprofessional Care Pathway for Acute Exacerbations of Chronic Obstructive Pulmonary Disease

Abstract

Introduction: Chronic obstructive pulmonary disease (COPD) is a common condition associated with an increasing mortality and morbidity. There are also significant economic implications with hospital admission accounting for the majority of the total COPD health care expenditure. Mild exacerbations of COPD can be treated at home; severe exacerbations require hospitalization. The purpose of this programme of care was to integrate and optimize treatment using current guidelines. Methods: This was a prospective study of management of severe exacerbations of COPD following implementation of a structured care pathway. The project was based at a district general hospital in inner city Belfast. Key measures of improvement were length of hospital stay, readmission rates within one month and hospital mortality. A multidisciplinary care pathway incorporated a score that was developed with one point for each of the following markers of a severe exacerbation: dyspnoea at rest, bed bound, tachypnoea (>25), tachycardia (>110), pyrexia (>38.5), use of accessory muscles of respiration and peripheral oedema. We have called this the ‘Mater COPD score’. The aim was for optimal management, education and identification of appropriate time for discharge. Patient treatment was standardized using oral steroid therapy, nebulized bronchodilators (air cylinders were used to provided nebulization where appropriate) and antibiotic therapy. Results: A total of 85 patients were studied, 40 men with a mean (SEM) age of 68.6 (1.7) years. The mean COPD score on admission was 2.3 (range 0–6). Mean score on discharge was 0.4 (range 0–3). Mean forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC) were 0.97 and 1.83 L, respectively. Seven patients were readmitted within one month. The mean length of an episode was reduced from 9.4 to 5.5 days, with a national average of 9.7 days at that time. However, delayed discharge in 25 cases (due to co-morbidity, social problems or other factors) resulted in the overall length of stay being reduced to 6.5 days. Continued follow-up using this pathway reduced the length of stay of all admissions with COPD by four days to 5.4 days. Nebulizers were routinely changed from oxygen driven to air driven. There was a 1700% increase in air cylinders used over the two years following introduction. This was associated with a 57% reduction in mortality. Conclusions: A multidisciplinary care pathway in the management of acute exacerbations of COPD ensures optimal treatment for patients and results in a significant reduction in the length of stay and a reduced mortality rate without increasing readmission rates.

Impact of a care pathway for COPD on adherence to guidelines and hospital readmission: a cluster randomized trial

“…Due to limited statistical analysis and weak study design, the internal validity of results is limited 12–15. Our study confirmed that the implementation of a CP significantly reduces the 30 days readmission rate 32,33…”

Interventions to standardise hospital care at presentation, admission or discharge or to reduce unnecessary admissions or readmissions for patients with acute exacerbation of chronic obstructive pulmonary disease: a scoping review

“…McManus et al noted that their score-based admission decision model was associated with a 4% drop in 1-month readmission rate and a 57% reduction in-hospital mortality. 41 Admission through to discharge [37][38][39][40][41][42] Admission through to discharge 46 Discharge planning [43][44][45] Admission through to discharge 48 49 Intervention elements Multidisciplinary team design 29-33 35 Initial assessment or investigation 29 30 35 36 Initial treatment or medication 29 30 34-36 Respiratory specialist consultation 29-31 35 36 Patient education [31][32][33] Discharge planning 31-33 35 36 Specialist service referral (eg, smoking cessation, occupational therapy) 29 31-36 Follow-up plan [31][32][33][34][35] Multidisciplinary team design 37 40-42 44 Assessment/investigation at presentation 40 Assessment/investigation at admission 37 39 41 Initial or ongoing treatment/medication prompts 37 38 40-42 Patient education 38 40-42 Specialist service referral (eg, smoking cessation, occupational therapy) [37][38][39][40][41][42] Disch...…”

“…Vanhaecht et al used QI methods and an auditfeedback approach to help hospital teams to understand care processes within their setting, to identify gaps in care and to generate plans for improvement. 38 Audit was also used by McManus et al 41 The designated coordinator role aided pathway compliance, 37 39 41 however, difficulties arose if an AECOPD admission was not identified, and therefore, did not receive standardised care. 39 42 Two papers noted attributed enhanced teamwork practices and reduced patient anxiety to implementation of the care pathway.…”

“…However, the benefits of investing in the standardisation of care and reducing unnecessary readmissions cannot be underestimated given the economic burden of COPD hospitalisation and impact on patient QoL. Care bundles and care pathways, when reliably implemented, have been shown to standardise care and improve care outcomes for patients with AECOPD [29][30][31][32][33][34][35][36][37][38][39][40][41][42] and other chronic conditions or clinical situations. [51][52][53] Similarly, interventions overseen by a dedicated coordinator role, whether as case manager or health coach, have had positive impact on care standardisation, 47 LOS, 45 readmission rate, 43-46 49 and QoL, 43 44 46 49 self-belief 48 or satisfaction.…”

The impact of care pathways for exacerbation of Chronic Obstructive Pulmonary Disease: rationale and design of a cluster randomized controlled trial

“…Up to now two non-randomized trials about the impact of a care pathway for inpatient management of COPD exacerbation are published [ 26 , 27 ]. The studies have been conducted between 2000 and 2001, and the methodology was rather weak.…”